Pancreatitis: Difference between revisions

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== Definition ==
==Background==


* Inflammation of the pancreas
*Inflammation of the pancreas


== Etiology ==
=== Etiologies ===
*'''[[Gallstone]]'''
*'''Alcohol'''
*Tumour/Trauma
*Scorpion sting (Trinidadian)
*Microbiological
**Viral: [[Mumps]], [[Rubella]], [[Varicella]], [[Viral hepatitis]], [[CMV]]/[[EBV]]/[[HIV]], [[Coxsackievirus]]/[[Echovirus]]/[[Adenovirus]]
**Bacterial: [[Mycoplasma]], [[Campylobacter]], [[Mycobacterium tuberculosis]], [[Mycobacterium avium intracellular]], [[Legionella]], [[Leptospirosis]]
**Parasitic: [[Ascariasis]], [[Clonorchiasis]], [[Echinococcus]]
*Autoimmune: [[SLE]], [[Polyarteritis nodosa]], [[Crohn disease]]
*Surgery: [[ERCP]]
*[[Hyperlipidemia]]
*[[Hypercalcemia]]
*[[Hypothermia]]
*Emboli/Ischemia
*Drugs
**[[Steroids]]
**[[Azathioprine]]
**[[Furosemide]]
**[[Mercaptopurine]]
**[[Estrogen]]
**[[Methyldopa]]
**H<sub>2</sub> blockers
**[[Valproic acid]]
**[[Antibiotics]]: [[ampicillin]], [[penicillin]], [[ceftriaxone]], [[isoniazid]], [[macrolides]], [[metronidazole]], [[nitrofurantoin]], [[rifampin]], [[sulfonamides]], [[tetracyclines]]
**[[Antivirals]]: [[didanosine]], [[interferon]]/[[ribavirin]], [[nelfinavir]], [[ritonavir]]
**[[Antifungals]]: [[5-fluorouracil]], [[pentamidine]], [[stibogluconate]]
**[[Acetaminophen]]
**[[Salicylates]]
**[[Methanol]]
**[[Organophosphates]]


==Clinical Manifestations==
* Gallstones
* Ethanol
* Tumour/Trauma
* Scorpion sting (Trinidadian)
* Microbiological
** Viral
*** Mumps
*** Rubella
*** Varicella
*** Viral hepatitis
*** CMV/EBV/HIV
*** Coxsackie virus/Echovirus/Adenovirus
** Bacterial
*** Mycoplasma
*** Campylobacter
*** Mycobacterium tuberculosis
*** Mycobacterium avium intracellular
*** Legionella
*** Leptospirosis
** Parasitological
*** Ascariasis
*** Clonorchiasis
*** Echinococcus
* Autoimmune
** SLE
** Polyarteritis nodosa
** Crohn's disease
* Surgery: ERCP
* Hyperlipidemia
* Hypercalcemia
* Hypothermia
* Emboli/Ischemia
* Drugs
** Steroids
** Azathioprine
** Furosemide
** Mercaptopurine
** Estrogen
** Methyldopa
** H2 blockers
** Valproic acid
** Antibiotics
** Acetaminophen
** Salicylates
** Methanol
** Organophosphates


*[[Causes::Acute abdominal pain]], usually [[Causes::epigastric pain|epigastric]], sometimes radiating to the back
== Clinical Manifestations ==
*[[Causes::Nausea]] and [[Causes::vomiting]]
*[[Causes::Fever]]
*[[Causes::Dyspnea]]
*Can lead to both endocrine and exocrine dysfunction, including [[diabetes mellitus]] and [[malabsorption]]


=== Prognosis ===
* Acute abdominal pain, usually epigastric, sometimes radiating to the back
* Nausea, vomiting
* Fevers
* Dyspnea


====Ranson's Criteria====
== Management ==


*On presentation
=== Pancreatic necrosis ===
**Sugar &gt; 10
**WBC &gt; 16k
**Elderly &gt; 55 years
**LDH &gt; 350
**AST &gt; 250
*After 48h
**Hct drop &gt;10% from admission
**BUN increase &gt;5 mg/dL (&gt;1.79 mmol/L) from admission
**Ca &lt;8 mg/dL (&lt;2 mmol/L) within 48 hours
**Arterial pO2 &lt;60 mmHg within 48 hours
**Base deficit (24 - HCO3) &gt;4 mg/dL within 48 hours
**Fluid needs &gt; 6L within 48 hours


====BISAP====
* Two forms
** Acute necrotizing pancreatitis, which is present at the start, and is usually phlegmonous
** Walled-off necrosis, which develops over the course of illness, and is usually an organized collection
* Both are sterile and both can become infected
* No antibiotics warranted in acute necrotizing pancreatitis
* Infection usually develops after about 10 days
* If necrosectomy is indicated, it should be delayed by at least 4 weeks


*BUN &gt; 8.9
=== Splenic vein thrombosis ===
*Impaired LOC
*SIRS
*Age &gt; 60
*Pleural effusion


== Differential Diagnosis ==
* Monitor


* Other causes of [[acute abdominal pain]], including [[peptic ulcer disease]], [[gallstones]], [[cholangitis]], [[cholecystitis]], [[gastrointestinal perforation]], [[intestinal obstruction]], [[mesenteric ischemia]], and [[hepatitis]]
== Prognosis ==


=== Ranson's criteria ===
== Diagnosis ==


* Made based on the presence of two of the following three criteria:
* On presentation
** Compatible history
** Sugar &gt; 10
** Elevated lipase or amylase
** WBC &gt; 16k
** Characteristic findings on imaging
** Elderly &gt; 55 years
** LDH &gt; 350
** AST &gt; 250
* After 48h
** Hct drop &gt;10% from admission
** BUN increase &gt;5 mg/dL (&gt;1.79 mmol/L) from admission
** Ca &lt;8 mg/dL (&lt;2 mmol/L) within 48 hours
** Arterial pO2 &lt;60 mmHg within 48 hours
** Base deficit (24 - HCO3) &gt;4 mg/dL within 48 hours
** Fluid needs &gt; 6L within 48 hours


=== BISAP ===
==Management==


===Pancreatic Necrosis===
* BUN &gt; 8.9

* Impaired LOC
*Two forms
* SIRS
**Acute necrotizing pancreatitis, which is present at the start, and is usually phlegmonous
* Age &gt; 60
**Walled-off necrosis, which develops over the course of illness, and is usually an organized collection
* Pleural effusion
*Both are sterile and both can become infected
**No antibiotics warranted in acute necrotizing pancreatitis
**Infection usually develops after about 10 days
*For patients with walled-off pancreatic necrosis, either sterile collections with severe symptoms, or suspected infection, they should be assessed for drainage[[CiteRef::baron2020am]]
**Options include IR-guided drainage, EUS-guided drainage, or endoscopic necrosectomy
**In general, if necrosectomy is indicated, it should be delayed by at least 4 weeks for the collection to mature
**Percutaneous drainage has a risk of pancreatocutaneous fistula (about 30% if done without some form of surgical debridement)[[iteRef::ross2014du]][[CiteRef::van brunschot2018en]]

===Splenic Vein Thrombosis===

*Monitor

== Further Reading ==

* American Gastroenterological Association Clinical Practice Update: Management of Pancreatic Necrosis. ''Gastroenterology''. 2020;158(1):67-75.e1. doi: [https://doi.org/10.1053/j.gastro.2019.07.064 10.1053/j.gastro.2019.07.064]. PMID: [https://pubmed.ncbi.nlm.nih.gov/31479658/ 31479658].


[[Category:Gastroenterology]]
[[Category:Gastroenterology]]

Latest revision as of 16:30, 10 April 2026

Background

  • Inflammation of the pancreas

Etiologies

Clinical Manifestations

Prognosis

Ranson's Criteria

  • On presentation
    • Sugar > 10
    • WBC > 16k
    • Elderly > 55 years
    • LDH > 350
    • AST > 250
  • After 48h
    • Hct drop >10% from admission
    • BUN increase >5 mg/dL (>1.79 mmol/L) from admission
    • Ca <8 mg/dL (<2 mmol/L) within 48 hours
    • Arterial pO2 <60 mmHg within 48 hours
    • Base deficit (24 - HCO3) >4 mg/dL within 48 hours
    • Fluid needs > 6L within 48 hours

BISAP

  • BUN > 8.9
  • Impaired LOC
  • SIRS
  • Age > 60
  • Pleural effusion

Differential Diagnosis

Diagnosis

  • Made based on the presence of two of the following three criteria:
    • Compatible history
    • Elevated lipase or amylase
    • Characteristic findings on imaging

Management

Pancreatic Necrosis

  • Two forms
    • Acute necrotizing pancreatitis, which is present at the start, and is usually phlegmonous
    • Walled-off necrosis, which develops over the course of illness, and is usually an organized collection
  • Both are sterile and both can become infected
    • No antibiotics warranted in acute necrotizing pancreatitis
    • Infection usually develops after about 10 days
  • For patients with walled-off pancreatic necrosis, either sterile collections with severe symptoms, or suspected infection, they should be assessed for drainage1
    • Options include IR-guided drainage, EUS-guided drainage, or endoscopic necrosectomy
    • In general, if necrosectomy is indicated, it should be delayed by at least 4 weeks for the collection to mature
    • Percutaneous drainage has a risk of pancreatocutaneous fistula (about 30% if done without some form of surgical debridement)ross2014du2

Splenic Vein Thrombosis

  • Monitor

Further Reading

  • American Gastroenterological Association Clinical Practice Update: Management of Pancreatic Necrosis. Gastroenterology. 2020;158(1):67-75.e1. doi: 10.1053/j.gastro.2019.07.064. PMID: 31479658.

References

  1. ^  Todd H. Baron, Christopher J. DiMaio, Andrew Y. Wang, Katherine A. Morgan. American Gastroenterological Association Clinical Practice Update: Management of Pancreatic Necrosis. Gastroenterology. 2020;158(1):67-75.e1. doi:10.1053/j.gastro.2019.07.064.
  2. ^  Sandra van Brunschot, Janneke van Grinsven, Hjalmar C van Santvoort, Olaf J Bakker, Marc G Besselink, Marja A Boermeester, Thomas L Bollen, Koop Bosscha, Stefan A Bouwense, Marco J Bruno, Vincent C Cappendijk, Esther C Consten, Cornelis H Dejong, Casper H van Eijck, Willemien G Erkelens, Harry van Goor, Wilhelmina M U van Grevenstein, Jan-Willem Haveman, Sijbrand H Hofker, Jeroen M Jansen, Johan S Laméris, Krijn P van Lienden, Maarten A Meijssen, Chris J Mulder, Vincent B Nieuwenhuijs, Jan-Werner Poley, Rutger Quispel, Rogier J de Ridder, Tessa E Römkens, Joris J Scheepers, Nicolien J Schepers, Matthijs P Schwartz, Tom Seerden, B W Marcel Spanier, Jan Willem A Straathof, Marin Strijker, Robin Timmer, Niels G Venneman, Frank P Vleggaar, Rogier P Voermans, Ben J Witteman, Hein G Gooszen, Marcel G Dijkgraaf, Paul Fockens, Eric R Manusama, Mohammed Hadithi, Camiel Rosman, Alexander F Schaapherder, Erik J Schoon. Endoscopic or surgical step-up approach for infected necrotising pancreatitis: a multicentre randomised trial. The Lancet. 2018;391(10115):51-58. doi:10.1016/s0140-6736(17)32404-2.

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